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LET THE FLYER BEWARE - Awareness of the risks of commercial flight and how to prepare for them are keys to safer air travel

Oct 1, 2001 While the catastrophic events of September 11th turned all of our attention to the dangers posed by terrorism and launched the airlines and the federal government into a long overdue revamping of airport and in-flight security, many, less publicized, health hazards still present a very real risk to the well-being of the commercial flier.

This month's newsletter is designed to increase awareness among our subscribers concerning a number of specific health risks which may affect one-time as well as frequent fliers.

I. In flight emergency medical equipment:

A. Emergency Medical Kit (required on all US-based airlines)

Item / Quantity
Sphygmomanometer / 1
Stethoscope / 1
Oropharyngeal airways / 3 (3 sizes)
Syringes / 4 (different sizes, 2 sets)
Needles / 6 (different sizes, 2 sets)
50% dextrose injection, 50 ml. / 1
Epinephrine 1:1,000 single dose ampule / 2
Injectable diphen-hydramine (Benadyrl) single dose ampule / 2
Nitroglycerine tablets / 10
Instructions for use of medications / 1
Protective latex gloves or equivalent / 1 pair

The emergency medical kit may only be opened during flight when authorized by a physician (on board or from the airline's medical department)

B. Emergency First-Aid Kit: Contents are limited and intended for basic emergency care only.

C. Automatic External Defibrillators: Now provided by a number of airlines along with flight personnel trained in their use.

D. "Enhanced" Medical Kit: These upgraded medical kits have been installed by some airlines and contain a wide variety of acute cardiac life support drugs and equipment.

E. Oxygen: Supplemental oxygen is available on an emergency basis only. (Flow rates vary from 2 to 8L per minute). There is a fee for this service which requires a minimum of 24 to 47 hours advanced notice as well as a medical certificate certifying the passenger is cleared to fly at a relative cabin altitude of 8,000 feet and specifying the flow rate and type delivery mask to be used. (Note: passengers cannot bring their own oxygen on board).

F. Respiratory equipment: Other equipment such as nebulizers and pediatric mechanical ventilators may be used on board, but must be pre-approved to prevent interference with sensitive electronic aviation equipment and must comply with applicable Federal Air Regulations (FARs).

II. Cardiovascular contraindications:

The following cardiovascular conditions are generally regarded as contraindicated to commercial airline flight (See Aerospace Medical Association guidelines, 1997; American Airlines Medical Department informational handout):

a. Uncomplicated myocardial infarction occurring with three weeks of flight

b. Complicated myocardial infarction occurring with six weeks of flight

c. Unstable angina

d. Severe, decompensated congestive heart failure

e. Uncontrolled hypertension

f. Coronary artery bypass grafting performed with two weeks of flight

g. Cardiovascular accident occurring within two weeks of flight

h. Uncontrolled ventricular or supraventricular tachycardia

i. Eisenmenger's syndrome

j. Severe symptomatic valvular heart disease

III. Precautions for passengers with cardiac disease

There are some basic procedures and preparations that passengers with various forms of cardiac disease can take before flying:

a. Have a sufficient supply of all cardiac medications (in a labeled container) and keep them in carry-on luggage.

b. Carry a copy of most recent electrocardiogram.

c. While pacemakers and implanted cardiac devices are not affected by airport security devices, any new or unfamiliar implanted devices should be cleared for inspection by the manufacturer.

d. Arrange for supplemental oxygen during flight if needed.

IV. Precautions for passengers with diabetes:

Diabetics will avoid most problems if they follow a few simple rules before flying:

a. Pack twice as much medications and supplies as needed. One half of this should be kept in a carry-on bag.

b. Written instructions for administration of medications should be carried in carry-on bag.

c. Blood testing equipment (including an extra battery for glucose meter) should be kept in carry-on bag.

d. Passenger should carry personal identification card, diabetes identification card, personal physician's business card, a set of prescriptions (to be filled in the event medications are lost or stolen), glucose tablets or another form of sugar to treat low blood sugar).

V. Pregnant Women

Generally, pregnant women are advised not to fly when approaching their expected delivery date. Even brief flights are not recommended within one week of expected delivery. This is to avoid in-flight deliveries rather than to guard against any harm to the fetus.

Pregnant women should request an aisle seat in order to stretch their legs and walk about the cabin as much as possible. Isometric leg exercises are also advised, especially during extended flights.

Seat belts should be worn whenever seated and the belt should be positioned low around the pelvis to reduce the possibility of fetal injury. Pregnant women should also be aware of the potential for dehydration (due to low cabin humidity), motion sickness and gastrointestinal discomfort. Availability of medical care and insurance coverage at the point of destination should be checked in advance.

Finally, any women with a history of complicated pregnancies or complicating factors for the current pregnancy should not fly.

VI. Ear conditions

People suffering from conditions such as middle ear infections, effusions, sinusitis or allergies or infections creating nasal congestion, should check with their physician before flying. Congestion should be controlled as much as possible to avoid simple (pain) or severe (rupture of tympanic membrane) complications.

Those having undergone recent surgery involving the inner or middle ear should not fly.

Simple ear problems can usually be controlled or alleviated by the use of decongestants or effective Valsalva maneuver (closing the nose with the thumb and index finger and exhaling gently with the mouth closed), chewing gum and frequent swallowing. Infants should be given a bottle or pacifier to avoid discomfort, especially during take-off and landing.

VII. Recent surgical procedures:

All potential passengers who have recently undergone any surgical procedure should check with their doctor before flying. In certain situations, a physician's certificate may be required before flying.

Many types of surgery such as abdominal, neurological, laproscopic, ophthalmological and thoracic, are associated with pressure related problems caused by the expansion of trapped gases.

VIII. Other conditions requiring attention:

a Scuba divers - should wait 12 hours (1 dive per day) to 24 hours (multiple or deep dives) before flying.

b. Jet lag - (physiologic reaction to traveling long distances in short periods of time) - some suggestions include:

1. Sleep well before beginning trip

2. Keep sleep amounts (in a 24 hour period) the same as at home

3. Avoid excessive alcohol

4. Avoid overeating

5. Attempt to stay on home time.

6. Adjust as quickly as possible to new time zone

7. Moderate exercise

8. Limit use of sleep medications

c. Orthopedic injuries: Use bi-valve casts to avoid circulatory problems. Keep extremely elevated. Before flight, release air from pneumatic splints (if allowed).

d. Epilepsy: Wear identification bracelet or other easily found epilepsy identification. Carry anti-epileptic medications in carry-on luggage. Discuss a temporary small increase in medication with your doctor.

e. Psychiatric conditions: Avoid alcohol and consider using a mild sedative. Notify airline in advance. Travel with a responsible companion if possible.

f. Medical devices with pneumatic components such as feeding tubes, pneumatic splints, urinary catheters and other closed infusion devices should be capped off during take-offs and landings.

g. Dehydration: Since cabin humidity levels are usually less than 25%, passengers often experience dryness in the eyes, nose and throat. Contact lens wearers can experience irritation. Suggestions for dealing with these problems include:

1. Avoid alcohol, coffee, tea, and other diuretics

2. Drink water or juices frequently

3. Wear glasses instead of contact lenses if possible

4. Use a skin moisturizer

h. Motion sickness: Can be brought on by turbulence or staring at moving objects. Over-the-counter and prescription medications are usually effective. You should consult your doctor, however, in this regard. Non-medication suggestions include pressure bands, keeping your eyes fixed on a non-moving object and looking at the ground, sea or horizon if possible.

i. Muscle problems: These include tension, fatigue, aches and stiffness. Recommendations include walking about the cabin occasionally, doing exercises such as ankle circles, foot pumps, knees lifts, shoulder rolls and knee to chest, for 3-4 minutes every hour if possible.

IX. Conditions being studied

a. Toxic cabin air: Currently the focus of various studies and legislative inquiry. Contaminants include hydraulic fluid, engine oil, pesticides (especially on all flights into Australia and New Zealand). Complications may include simple flu-like symptoms and neurological damage. The danger to infants is even more serious.

b. Brain shrinkage: Researchers claim that chronic jet lag can have anywhere from mild to serious effects on the brain. More studies are being done but it is clear that repeated jet lag experience by frequent fliers and airline personnel does effect brain function.

X. Economy Class Syndrome

(Deep Vein Thrombosis):

One of the most serious problems associated with frequent flying and longer flights is the risk of developing life-threatening blood clots (Deep Vein Thrombosis or DVT).

The risk factors for DVT associated with airline travel are:

1. Inactivity during flights.

2. Restrictive seating (hence the term, "Economy Class Syndrome").

3. Long flights (3,100 to 4,500 miles [1/2,5000,00);

4,500 to 6,215 [1/376,000], over 6,215 miles

[1/210,000].

4. Consumption of alcoholic beverages.

5. Age - elderly passengers are at greater risk.

6. Diet - overweight passengers are more at risk.

7. Air quality - dry, recirculated air may be a factor.

8. Dehydration.

9. Constrictive clothing.

10. Smoking while in flight.

11. Recent surgery.

12. Heart failure.

13. Blood clotting abnormalities.

14. History of DVT (personal or family).

15. Pregnancy.

16. Stroke.

17. Chronic illness.

18. Some oral contraceptives

19. Low cabin pressure

There are, however, a number of things that can be done to reduce the risk of DVT when traveling by air:

1. Book a better seat (price-wise) or a seat in a better location (by an exit).

2. Wear support stockings.

3. Avoid alcoholic beverages and other diuretic drinks such as tea and coffee containing caffeine.

4. Drink plenty of water or juice.

5. Walk up and down the cabin once an hour.

6. Exercise - ankle circles, foot pumps, lifting toes up and down, shoulder rolls, etc.

Current estimates of those dying each year from fatal blood clots linked to flying are as high as 300 or more. Studies are being done with respect to repositioning airline seats, recommending the use of aspirin or prescription anti-coagulants to those in high-risk categories.

Symptoms of DVT include:

1. Breathlessness.

2. Lightheadedness.

3. Chest pain.

4. Tenderness in one calf that feels like an ache or tightness - pain increases when ankle is flexed.

5. Swelling or redness of leg.

6. Pain or discomfort over a deep vein.

7 No symptoms if clot forms in a vein other than an arm or leg.

Once DVT is suspected or diagnosed, immediate treatment is recommended. Some treatments include:

1. Get to a doctor or hospital emergency room immediately.

2. Have a Doppler (ultrasound) test done to confirm the clot.

3. Begin a regimen of blood-thinning medication.

4. Surgical intervention.

As always, your comments and suggestions are encouraged.
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